text:
Diagnosing Iron Deficiency
Prevention of Iron Deficiency
Treatment of Iron Deficiency
Cobalamin Deficiency
Study Assessment – Optional
Morton A, Glob. libr. women's med.,
ISSN: 1756-2228; DOI 10.3843/GLOWM.413143
The Continuous Textbook of Women's Medicine Series – Obstetrics Module
Maternal medical health and disorders in pregnancy
Volume Editor: Kenneth K Chen, MD, Alpert Medical School of Brown University, USA Originating Editor: Professor Sandra Lowe
Nutritional Anemia
First published: February 2021
Adam Morton
Senor Staff Specialist Endocrinology and Obstetric Medicine, Obstetric Medicine, Mater Health, South Brisbane, Australia
Study Assessment Option
By completing 4 multiple-choice questions (randomly selected) after studying this chapter readers can qualify for Continuing Professional Development awards from FIGO plus a Study Completion Certificate from GLOWM
See end of chapter for details
Anemia affects an estimated 30% of women of child-bearing age, and more than 40% of pregnant women worldwide. The highest prevalence of anemia in pregnant women is in South-East Asia (48.7%) and Africa (46.3%).1
Anemia in pregnancy is defined by the World Health Organization (WHO) as hemoglobin (Hb) less than 110 g/dL in the first and third trimesters, and less than 105 g/dL in the second trimester.
Micronutrient deficiencies are common in women of reproductive age, particularly in developing countries. A systematic review of data from 2005 to 2015 of reproductive age women in Ethiopia, Kenya, Nigeria and South Africa found the prevalence of anemia, iron deficiency, iron deficiency anemia, folate deficiency, zinc, vitamin A and iodine deficiencies to be 18–51%, 9–18%, 10%, 46%, 34%, 4–22% and 22–55%, respectively.2 The corresponding prevalence rates in pregnant women were 32–62%, 19–61%, 9–47%, 3–12%, 46–76%, 21–48% and 87%. Women of reproductive age in developing countries are particularly susceptible to micronutrient deficiencies due to women prioritizing the health of other family members and, thus, inequitable food distribution within households, lack of availability of food, lack of dietary diversity, and endemic infectious diseases. As a result, women may enter pregnancy with micronutrient deficiencies, which may be further exacerbated by the demands of pregnancy.
Iron deficiency is the most common cause of anemia in pregnancy, accounting for up to 75% of cases. In addition, iron deficiency anemia (IDA) affects 10% of postpartum women. It is estimated that an additional 500 mg of iron is required during pregnancy for expansion of red cell mass, 300–350 mg for the growing fetus and placenta, as well as 250 mg for peripartum blood loss. Physiologic requirements for iron absorbed are estimated to be 0.8 mg/day in first trimester, 5 mg/day in second trimester and 6 mg/day in third trimester.3 A typical Western diet provides only 50% of daily iron requirements for pregnant women.4 A significant proportion of women have inadequate iron stores in early pregnancy even in the absence of anemia. An observational study of 102 non-anemic first trimester women in the USA found that 37% were iron deficient based upon a transferrin saturation of less than 20%.5 Fourteen per cent had ferritin levels <30 ng/mL, 6% had ferritin levels <25 ng/mL, and 5% had ferritin levels <20 ng/mL. A recent study in Indian women found the prevalence of iron deficiency was 91% in first trimester.6
Risk factors for iron deficiency in pregnancy include low dietary intake, malabsorption, blood loss, adolescent pregnancy, obesity, gestational diabetes, hypertension, higher parity, a short interpartum period, and carrying multiple fetuses.
Serum ferritin is usually adequate for the diagnosis of iron deficiency, with the exception of where there is active inflammation, as ferritin acts as an acute phase reactant. Diagnostic thresholds for iron deficiency in pregnancy vary significantly. While WHO defines iron deficiency anemia based on a serum ferritin <15 ng/mL, pregnant women with serum ferritin levels <30 ng/mL are considered to be at risk for IDA in the United Kingdom, and in Denmark it is suggested that women with serum ferritin <70 g/mL be treated with iron supplements.7
Studies correlating the presence or absence of stainable marrow iron with serum ferritin indicated that a level of <30 ng/mL has a 92% sensitivity and 98% specificity for diagnosing iron deficiency, whereas a serum ferritin <10 ng/ml has only a 25% sensitivity in detecting iron deficiency.8,9
In the setting of acute inflammation measurement of transferrin saturation may be useful. Transferrin saturation <16% is considered a marker of functional iron deficiency.
The use of microcytosis in screening will underestimate the prevalence of IDA, as a fall in Hb commonly antedates the fall in mean corpuscular volume.10 Microcytosis was present in only 27.5–65% of patients with iron deficiency.11,12 Soluble transferrin receptor levels increase in iron deficiency, and are unaffected by inflammation. A meta-analysis of ten studies found that soluble transferrin receptor levels had a sensitivity of 86% and a specificity of 75% in detecting iron deficiency.13 The assay is not standardized and not widely available. Hepcidin regulates systemic iron bioavailability, determining how well oral iron is absorbed. Levels of hepcidin fall during pregnancy, women with undetectable levels transferring more maternally ingested iron to their fetus than women with detectable hepcidin. The utility of hepcidin levels as a biomarker of iron deficiency is being evaluated, one recent study suggesting that serum hepcidin is superior to Hb, serum iron, serum ferritin, transferrin saturation, and transferrin iron binding capacity as an indicator of IDA in pregnant women.14 Hepcidin may be particularly useful in detecting iron deficiency in the setting of infectious or inflammatory disease.
Based upon measures of erythrocyte and reticulocyte indices including reticulocyte Hb content and percentages of hypochromic erythrocytes and microcytic erythrocytes, Demmers et al. concluded that in contrast to iron-deficient nonpregnant women, low ferritin concentrations in pregnant women are not associated with functional iron deficiency.7 Iron metabolism might be differentially regulated for optimal fetal growth and development despite low maternal iron stores.
Portable point-of-care devices (POCD) for the assessment of Hb levels from capillary blood may be useful in remote areas.15,16 Detection of iron deficiency using POCD may also be useful particularly in remote areas and developing countries. A mobile phone device-coupled tool measuring serum ferritin using fingerprick blood samples displayed a correlation of 0.92 with a sensitivity of greater than 90% for predicting iron deficiency (ferritin <15 ng/mL) compared with a laboratory standard IMMULITE analysis of whole blood samples.17 Similarly an immunochromatographic assay-based point-of-care screening device quantified soluble transferrin receptor from a drop of serum within a few minutes with a correlation of 0.93 compared with ELISA of archived serum samples demonstrating its potential for point-of-care assessment of iron status.18 Additionally erythrocyte zinc-protoporphyrin/heme ratio was found to be a valid point-of-care biomarker to diagnose iron deficiency anemia.19
Appropriate dietary advice should be given to all women regarding healthy eating. Appropriate surveillance and treatment should be given regarding endemic infections that may cause anemia (e.g. hookworm, malaria).
Fortification of food with iron has met with a number of barriers. Fortified foods are often financially unavailable to the poorest segments of the population who have the greatest risk of micronutrient deficiencies.20 Food choices for fortification need to be chosen carefully in order to deliver greatest benefit to those individuals at highest risk. Coverage surveys in four African countries found fortification of wheat, maize and semolina flours contributed only 0–13% of recommended iron intake in women of reproductive age.21 A study in the Solomon Islands found that the potential benefit of fortification of wheat flour was likely to be limited to urban populations, and that fortification of rice would contribute significantly to the intake of iron, folic acid and zinc by women of reproductive age.22 Universal fortification of food with iron may place individuals with hemochromatosis at greater risk. Denmark and Sweden, however, ceased iron fortification of foods in 1987 and 1994, respectively, because of both a lack of evidence of benefit and concerns regarding hemochromatosis. The combined allele frequency of the H63D and C282Y mutations for hemochromatosis is only 2.6% in Africa, 1.9% in South-East Asia and 8.6% in the Indian subcontinent, compared with an allele frequency of up to 30% in Northern European populations, suggesting the benefit far outweighs risks in those areas where iron deficiency is highly prevalent.23
Iodized salt is an ideal carrier for food fortification as it is universally consumed independent of economic status.24 Previous attempts to fortify food with both iodine and iron together have been limited by iron negating the effect of iodine. Microencapsulation based technology enables the addition of iron without degradation or interaction, and currently double-fortified salt is reaching 60 million people in three states in India.
A stable quadruple fortification of salt with iodine, iron, folic acid and vitamin B12 that could provide up to 50% of the recommended dietary allowance (RDA) of folic acid and iron, and 100% of RDA of vitamin B12 and iodine has been pilot tested with high consumer acceptability.25 It is estimated this formulation would cost less than US$ 0.20 per person per annum.
Fortification of water with iron and vitamin C has been effective in improving ferritin and Hb in a number of studies.26,27,28,29
Because of the importance of adequate pre-pregnancy iron stores, WHO guidelines recommend once-weekly supplementation with 60 mg elemental iron and 2.8 mg folic acid in all non-pregnant women of reproductive age living in regions with a greater than 20% prevalence of anemia (most developing countries). This together with regular deworming has been shown to be effective in increasing iron stores, stabilizing Hb and reducing soil transmitted helminth infections over periods of several years.30 The equivalent of 60 mg of elemental iron is 300 mg of ferrous sulfate heptahydrate, 180 mg ferrous fumarate or 500 mg ferrous gluconate.
In countries where anemia prevalence is over 40%, WHO recommends daily elemental iron supplementation of 60 mg in pregnant women together with folic acid 0.4 mg.31 Routine supplementation with 15–30 mg/day of elemental iron is recommended in pregnancy in North America.4 Weekly therapy with 120 mg of iron appears to be an effective and safe alternative to daily therapy.32 UK guidelines differ in that routine supplementation of all pregnant women is not recommended, instead screening for anemia is performed in early pregnancy and at 26 weeks' gestation.33 The bioavailability of non-heme iron in foods of plant origin is low, and vegetarian women should be offered iron supplements at a recommended dosage of 30 mg/day.
In a study in which 133 pregnant African women were injected with 5-ml iron dextran complex in each buttock at their first antenatal visit, 84% of the treated group showed an improvement in Hb level (mean rise 1.025 g/dL) compared with 56% of women in a control group (mean rise 0.26 g/dL).34
Oral iron therapy commonly causes constipation, diarrhea and nausea, and non-adherence rates of prescribed oral supplements in pregnancy have been reported to be 27–46%.35 Recommendations for universal iron supplementation have not resulted in a consistent reduction in the incidence of iron deficiency anemia in pregnancy. Intermittent supplementation (2–3 times a week on non-consecutive days) produced similar maternal and infant outcomes to daily supplementation.
Iron salt preparations containing equivalent amounts of elemental iron have similar rates of side-effects.36 Controlled-release iron formulations have lower rates of epigastric pain and nausea, but no difference in discontinuation rates compared with ferrous sulfate.37,38 Absorption of iron may be increased by concurrent administration of vitamin C. Oral iron is likely to be ineffective in the setting of inflammatory bowel disease, and not absorbed in women who have undergone bypass bariatric surgery.
It is unclear as to whether iron supplementation in malaria endemic areas may increase the risk of infection.39 A 2015 systematic review and meta-analysis of pregnancy concluded that iron supplementation in pregnancy was associated with a temporal increase in Plasmodium vivax infections without a clear effect on Plasmodium falciparum risk.40 A 2018 review of clinical trials, however, concluded that iron supplementation in pregnancy did not increase the risk of malaria.41 In malaria-endemic areas, iron supplementation should occur in conjunction with appropriate malaria prevention, diagnosis, and treatment measures.
Where a woman is diagnosed with anemia in pregnancy, the daily dose of oral elemental iron should be increased to 120 mg per day until Hb is at least 110 g/dL.
A study comparing intramuscular administration of iron dextran (250 mg thrice weekly) to pregnant women with IDA resulted in more rapid improvement in Hb at 2, 4 and 6 weeks than oral ferrous sulfate (200 mg 3 times per day with vitamin C).42 The relative cost of parenteral iron dextran treatment was 4–8 times that of oral ferrous sulfate. In addition, intramuscular therapy required transport of the pregnant woman to and from the local hospital for administration in case of anaphylaxis, and was associated with pain at the injection site in 17%, skin staining in 3%, nausea in 10%, and headache in 7%. Intramuscular iron is therefore not recommended as first-line therapy.
A meta-analysis revealed pregnant women with anemia are 2.7 times more likely to achieve their target Hb with iron infusion (FeI) than oral iron, and to do so more rapidly and with less risk of adverse effects.43 Systematic reviews of oral and intravenous iron therapy for iron deficiency anemia in pregnancy demonstrated significant improvement in hematologic parameters though no improvement in clinically relevant outcomes.44,45 A possible contributor to the failure of FeI to improve maternal and fetal outcomes is the late administration – recent retrospective observational Australian studies reported administration of FeI to healthy women at a mean gestation of 34.6 weeks.46,47 FeI is usually avoided in first trimester because of uncertainty regarding teratogenicity.48 Twenty-two cases of intravenous iron administration in healthy women in first trimester have been described without adverse pregnancy outcome.49,50 Additionally, more than 600 pregnancies have been reported in women receiving chronic hemodialysis. Individuals being managed with hemodialysis typically receive 100 mg of intravenous iron weekly. The mean time at which pregnancy is diagnosed in women receiving chronic hemodialysis is 8 weeks, with the fetal malformation rate the same as in the general population, suggesting that intravenous iron in doses used for dialysis patients is not teratogenic in human pregnancy.
FeI products consist of a polynuclear iron core with a surrounding shell of carbohydrate for stability. In contrast to the high rate of adverse reactions to high molecular weight iron dextrans, current formulations have a low incidence of side-effects. The risk of major infusion reactions due to activation of the complement system has been estimated to be 1 in 200,000.51 Minor reactions requiring slowing of the infusion rate occur in 1 in 200. No increased risk of infection or precipitation of cardiac failure has been reported. Ferric carboxymaltose may be associated with hypophosphatemia in up to 50% of patients regularly tested post FeI.52 Onset occurred approximately 1 week after FeI, peaking in frequency at 2 weeks post FeI, and persisted for up to 5 weeks. The vast majority of cases of hypophosphatemia are asymptomatic – only nine cases of severe hypophosphatemia with musculoskeletal complications having been described to date, none of these in pregnancy. FeI products appear to have equivalent efficacy and safety. Formulations that may be given as a single infusion, such as ferric carboxymaltose, iron polymaltose and low molecular weight iron dextran, may be preferable.
Response to iron therapy is usually seen as a reticulocytosis within 1 week, a rise in Hb within 2 weeks, and an increase in serum ferritin within 3 weeks.
Lactoferrin is an iron-binding protein present in large quantities in colostrum, breast milk, external secretions and leucocytes. Its functions include gastrointestinal absorption of iron as well as antimicrobial, antioxidant, anti-inflammatory and anti-neoplastic activity. Lactoferrin has been approved by the FDA and European Food Safety Authority as a supplement in food products. Lactoferrin is taken orally twice a day. A meta-analysis of randomized trials found lactoferrin was significantly more effective than oral ferrous salts in improving Hb level after 4 weeks in pregnant women with moderate iron deficiency anemia, and was better tolerated.53 In a randomized controlled trial lactoferrin with health education resulted in a similar improvement in anemia to total dose infusion of iron dextran 4 weeks after treatment.54 The cost of lactoferrin may be a significant barrier to its widespread use. In an Egyptian study the cost of 4 weeks of lactoferrin therapy was $7.20US compared with $0.41US for treatment with ferrous sulfate.55
Several animal studies have demonstrated significant improvement in serum iron and Hb levels in IDA with the use of dissolving microneedle patches containing ferric pyrophosphate and iron dextran.56,57,58,59 Transdermal delivery of iron may be an alternative to intravenous and oral therapy in remote areas. Nasal delivery of nano-liposome encapsulated ferric ammonium citrate has been used to increase iron content in the brain of the rat without affecting the respiratory system.60
Folate deficiency complicates approximately 30% of pregnancies worldwide.61 The folic acid requirement during pregnancy increases by 50% to 150 mg per day. Dietary folate is absorbed in the jejunum. The total body content of folate is estimated to be 15–30 mg, half of these being in the liver, the remainder in blood and body tissues.62 Folate stores last approximately 3 months before deficiency occurs.
Folic acid fortification of foods (providing approximately 163 mg/day in the US) has resulted in a reduction in neural tube defects (NTD) in many countries. The neural tube closes around day 26 of gestation. Causes of folic acid deficiency include diets high in organic foods or low in carbohydrate, interference of absorption due to medications or medical conditions (celiac disease, inflammatory bowel disease, gastric bypass surgery), liver and renal disease, and alcohol excess.
Most pregnant women with folate deficiency anemia do not manifest macrocytosis.63 Red cell folate levels are a more accurate measure of folic acid deficiency than serum folate. A POCD using a fluorescence lateral flow assay to measure serum folate has been described and may be useful for measuring levels in areas remote to laboratory facilities.64
For the prevention of neural tube defects empiric supplementation with 0.4 mg folic acid per day is recommended from 3 months prior to attempting conception continuing throughout pregnancy and breastfeeding. In women with medical conditions predisposing to low folate levels as above, pregestational diabetes, medications that may lower folic acid levels (e.g. sulfasalazine, trimethoprim, triamterene), or a family history of NTD in second or third degree relatives, a dose of 1 mg folic acid per day is recommended pre-conception/first trimester, reducing to 0.4 mg per day at 12 weeks' gestation and continuing until cessation of breastfeeding. With maternal therapy with carbamazepine or sodium valproate, a parental or previous offspring history of NTD, or sickle cell anemia or thalassemia, 4–5 mg folic acid per day is recommended preconception/first trimester. A preconception/first trimester 1 mg/day dose is also recommended where there is a family history of cleft lip/palate, congenital heart defects, limb defects, urinary tract abnormalities and congenital hydrocephalus, as these may also represent folate-sensitive congenital malformations.
In the treatment of anemia due to folate deficiency, replacement may be achieved with a daily 5 mg oral dose for 4 months or 0.5–1 mg two or three times daily.65 Holotranscobalamin levels should always be measured prior to treating megaloblastic anemia, as therapy with folic acid may mask diagnosis of vitamin B12 deficiency increasing the risk of neurologic or hematologic complications.
Cobalamin deficiency is far less common than folate deficiency in pregnancy as substantial amounts of vitamin B12 are stored in the liver, enough to maintain supply for 3–6 years. Primary dietary sources of vitamin B12 are meats, fish, shellfish, and dairy products, absorption of B12 occurring in the terminal ileum. Dietary deficiency of B12 is common in vegans and those with low meat intake. The reported prevalence of B12 deficiency in early pregnancy is up to 70% in India. Women of South Asian ethnicity living in Vancouver demonstrated substantially lower vitamin B12 levels and higher rates of vitamin B12 deficiency and inadequacy in first trimester than women of European ancestry.66 Levels of B12 are lower in smokers, individuals with heavy alcohol intake, and in obese women.67 Low B12 is seen in more than 10% pregnant women with previous bypass bariatric surgery or sleeve gastrectomy.68 The long-term (>2 years) use of metformin may induce biochemical vitamin B12 deficiency, though whether this correlates with anemia or neurological complications is unclear. The prevalence of vitamin B12 deficiency in metformin-treated type 2 diabetic patients in a tertiary institution in Nigeria was 41%.69 Metformin used in the treatment of gestational diabetes mellitus did not result in lower holotranscobalamin levels than in insulin-treated women.70
B12 deficiency may manifest as maternal neurological or hematological complications, or as growth restriction, hypotonia, NTDs or loss of neuromotor skills in the neonate.71 Folate treatment may mask B12 deficiency by correcting megaloblastic anemia, while allowing neurological complications to progress. Thus, B12 levels should always be measured before commencing folate therapy.
Serum total vitamin B12 falls significantly in 20% of healthy women in pregnancy due to reduction in holohaptocorrin.72 Holotranscobalamin (active B12), the fraction of B12 that is available to cross the placenta, does not change and should be used as a guide to B12 deficiency in pregnancy.73 Methylmalonic acid (MMA) is a more specific functional indicator of B12 status than homocysteine, as the latter is also determined by folate and other B-vitamins.74 MMA and homocysteine assays are more expensive than B12 assays. Vitamin B12 levels vary significantly between different ethnicities, thus reference intervals during pregnancy need to be population and laboratory specific. A mobile POCD for measuring B12 was limited by a significant incubation time (3 h), multiple pipetting steps, and requirements for off-chip blood sample processing.75
The dietary requirement for vitamin B12 is 2.6 mg/day during pregnancy, and 2.8 mg/day during lactation.
B12 therapy may be administered orally, sublingually, intranasally, transdermally or parenterally. In women treated with oral cobalamin 1000 mg/day serum levels should be monitored to ensure adequate replacement. Sublingual therapy was more effective in increasing vitamin B12 levels than the standard intramuscular regimen.76 A daily low dose (50 mg) sublingual regimen was more effective than a 2000 mg once-weekly regimen in improving vitamin B12 levels in those with marginal deficiency.77
Other elements which may be a factor in nutritional anemia include zinc, copper, magnesium, B group vitamins, and vitamins A, C and E.78
Zinc requirements increase by 40% during pregnancy. The recommended daily allowance (RDA) is 11 mg per day, only 25% of which is absorbed. It is estimated that 25% of the world population is at risk of inadequate zinc intake, and deficiency is common in South Asia and Sub-Saharan Africa. Diets high in phytates and/or low in animal protein provide limited amounts of zinc. Zinc deficiency may also occur as a result of alcoholism, reduced absorption (celiac disease, bariatric surgery), gastrointestinal loss (Crohn's disease), and diuretic therapy. Zinc is an important co-factor in iron metabolism, and zinc deficiency aggravates IDA.79 Maternal zinc deficiency may also be associated with miscarriage, premature birth, intrauterine growth restriction, birth defects and neurological disorders.80 Point-of-care testing for serum zinc has been developed for the management of pediatric septic shock, giving a result in 10–20 minutes.81
Copper is involved in Hb synthesis, neurotransmission, iron oxidation and the formation of connective tissue disease.82 Copper deficiency may result in anemia, neutropenia, optic neuropathy, myelopathy, neuropathy and other neurologic dysfunction. Copper deficiency has been reported in 29–34% of pregnant women in India.83 Foods rich in copper include organ meats such as liver and kidney, shellfish, grains, nuts and seeds. The RDA for pregnancy is 1 mg per day. Causes of acquired copper deficiency include intake of excessive amounts of zinc and iron (which reduce copper absorption), previous upper gastrointestinal surgery, malabsorption syndromes, alcohol excess and malnutrition. Serum copper and ceruloplasmin levels rise approximately two-fold in healthy pregnancy compared with non-pregnant women.84 Twenty-four hour urine copper levels may be useful in the diagnosis of copper deficiency in pregnancy.
Hypomagnesemia (hypoMg) is common in pregnancy in developing countries and low-income communities. Maternal hypoMg has been reported in 40–60% of pregnant women in South Asia, and 57% of pregnant women in the Sudan.85 It is unclear as to whether hypoMg may represent a direct cause, a consequence of other disease processes, or an epiphenomenon in adverse pregnancy outcomes.86 Mg absorption occurs primarily in the ileum and colon. Mg intake depends on the Mg concentration in drinking water and foods. Green leafy vegetables, grain, cereal, nuts and legumes are rich in Mg. Intermittent concentrations of Mg are found in fruit, meat and fish, and low Mg concentrations are present in dairy products. Refining and cooking of foods result in significant loss of Mg. There is a physiological decline in serum Mg in healthy pregnancy from a preconception mean of 0.93 mmol/L to a nadir mean of 0.63 mmol/L in third trimester. Several studies have shown a joint effect between magnesium and iron intake in relation to anemia.87 The China Health and Nutrition survey found serum magnesium was inversely associated with anemia in men and women.88 A high intake of magnesium was associated with a lower prevalence of anemia. In Sudanese women in early pregnancy low magnesium and low ferritin were associated with anemia. Gestational magnesium deficiency may be associated with hematological and teratogenic damage.89 Magnesium-deprived rats manifest a microcytic anemia with intense reticulocytosis suggestive of hemolysis.90 A high-magnesium diet improved anemia in a murine model of β-thalassemia.91
Riboflavin (vitamin B2) deficiency is endemic in populations where the staple diet consists of rice and wheat, with minimal or no consumption of dairy products or meat. Vegans and vegetarians are at highest risk of deficiency. Vitamin B2 degrades in light, and is also lost by the boiling or cooking of vegetables and grains. Deficiency of riboflavin tends to occur in combination with deficiency of other B group vitamins. Symptoms and signs include normocytic normochromic anemia with reticulocytopenia, atrophic glossitis, dermatitis and cheilosis.92 Bone marrow examination revealed selective hypoplasia of erythroid precursors, and ferrokinetics showed marked reduction of incorporation of iron into red blood cells.
Pyridoxine (vitamin B6) deficiency is an uncommon cause of anemia in pregnancy. Vitamin B6 deficiency is typically associated with a hypochromic microcytic anemia, and should be considered where anemia in pregnancy is unresponsive to iron therapy.93 Two cases of vitamin B6 responsive megaloblastic anemia in pregnancy have also been reported.94
Vitamin A deficiency has been reported in 15% of pregnant African women and 24% of pregnant Egyptian women.95 Eight per cent of pregnant women in Africa have night blindness.96 Daily requirements for vitamin A increase during pregnancy, the RDA being 800 mg/day. Vitamin A deficiency was associated with a 1.8 times greater risk of anemia than women without vitamin A deficiency in Bangladesh.97 The mechanism of anemia with vitamin A deficiency is unclear, postulated mechanisms including effects on erythropoietin gene transcription, modulation of iron metabolism and anti-infective properties. Vitamin A supplementation has been shown to improve Hb concentrations and reduce maternal anemia in communities where vitamin A deficiency is common.98,99
Vitamin C deficiency has been reported in up to 80% of pregnant women in Nigeria, 68% of pregnant women in Uganda, 31% of parturients in Brazil, and 75% of adults in rural India.100,101,102 Symptoms and signs of vitamin C deficiency include arthralgia, myalgia, follicular hyperkeratosis, spontaneous bleeding, gum hyperplasia, mood disturbance, jaundice, fever and anemia. Adult scurvy should be particularly considered in the setting of spontaneous petechiae, ecchymoses and mucosal bleeding. Scurvy-associated anemia may be microcytic, normocytic or macrocytic, and may be associated with hemolysis.103,104 The findings on blood film and bone marrow biopsy do not help differentiate scurvy-related anemia from the other megaloblastic anaemias, and measurement of vitamin C level is the gold standard for establishing diagnosis.105
Vitamin E deficiency is rare, occurring predominantly in the setting of fat malabsorption, rare disorders of fat metabolism and premature birth. Individuals in developing countries are at greater risk of vitamin E deficiency due to poor nutritional status and higher prevalence of oxidative stressors such as HIV infection and malaria which accelerate vitamin E depletion.106 Vitamin E deficiency is characterized by peripheral neuropathy, ataxia and anemia. Vitamin E may have a role in preventing stress-induced premature erythrocyte lysis by prevention of oxidation of polyunsaturated fatty acids and thus stabilizing the red blood cell membrane.107 Vitamin E deficiency is common in many hereditary hemolytic anemias. Supplementation with vitamin E reduces hemolysis and improves Hb in individuals with sickle cell disease, thalassemia and glucose-6-phosphate dehydrogenase deficiency.108 Vitamin E supplementation may also have a role in improving anemia in premature infants and patients with chronic kidney disease.109,110 A preliminary study of 30 mildly anemic adults found vitamin E supplementation for 3 months increased Hb.111 Major dietary sources of vitamin E include vegetable oils, nuts, whole grains and green leafy vegetables. The RDA for α-tocopherol in pregnancy is 15 mg/day.
Nutritional anemia is extremely common in women of worldwide, particularly in developing countries. Women of reproductive age frequently have micronutrient deficiencies at the time of conception, which may be further exacerbated by the demands of pregnancy and the fetus. Prevention of nutrient inadequacies may be best achieved by multiple nutrient fortification of water supplies and dietary substances which are cheap and are consumed universally such as salt. Point-of-care diagnostic testing may have a significant role in the diagnosis of nutritional anemias in remote areas. Treatment of nutritional anemia must consider the optimal mode of delivery taking medication side-effects, adherence, cost, the frequency of delivery, need for patient travel and administration supervision into account.
Nutritional anemia in women of reproductive age is highly prevalent, particularly in Africa and South-East Asia.
Iron deficiency is the most common cause of anemia in pregnancy.
Diagnostic thresholds for iron deficiency vary significantly.
There is a high prevalence of non-adherence with oral iron therapy because of gastrointestinal side-effects.
Significant reactions to intravenous iron in second and third trimester are extremely rare.
More research is needed regarding the safety of intravenous iron infusions in first trimester.
Microcytosis is not a good screening test for iron deficiency.
Most individuals with anemia due to folate deficiency do not manifest a macrocytosis.
Point-of-care devices may enable testing for micronutrient deficiencies in remote areas.
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text:
Bizmut subgalat je organsko jedinjenje, koje sadrži 7 atoma ugljenika i ima molekulsku masu od 394,091 -{Da}-.

Osobine

Reference

Literatura

Spoljašnje veze

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Феноли
Бензојеве киселине
Једињења бизмута

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FONDA, NY – We are pleased to announce that on July 20th, 2019 BBL Construction Services & Recovery Sports Grill will present Hall of Fame night at the 'Track of Champions' with the Sunoco RacingModifieds, Crate 602 Sportsman, Limited Sportsman, Pro Stocks 'Best of 8 Series', Street Stocks & the Mohawk Valley Vintage Dirt Modified Series (MVVDMS).
Gates Open @ 4:00 p.m, Hot Laps @ 6:00 p.m. and Racing starts @ 7:00 p.m.
Welcome home BBL Construction Services,Recovery Sports Grill, Brian C. R. Gleason, Matt DeLorenzo, families & partners!


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Downtown Memphis has a long history with entrepreneurs and innovators. The very first modern grocery store opened on Downtown's Main Street, just a few blocks down from the world's first five and dime, Kress, and right down the street from where rock 'n roll was launched onto the air and into the world by Elvis. We're an unconventional bunch ... gritty risktakers who don't like to be told we can't do something. That unbridled spirit of the entrepreneur continues today in Downtown, and with guiding hands from some amazing organizations, our startups and entrepreneur community get a lot of support.
StartCo is the organization helping startups launch
new ventures through a variety of programming and resources.
The Entrepreneurship-Powered Innovation Center (EPIcenter) is a collaborative and community-wide strategic initiative that is helping entrepreneurs conceive, launch and scale businesses in the Memphis region. EPIcenter serves as a central point of contact for the region's ecosystem and coordinates resources from various organizations in the community such as accelerators, incubators, mentors, investors, networking programs, and technical assistance programs for entrepreneurs. EPIcenter also represents the complete picture of the region's entrepreneurial activity and resources in high-growth, scalable startups and businesses.
Memphis ranked highly for millennial job seekers
Memphis has made another top 10 list — this time it's the best places for millennial job seekers in the state of Tennessee.
Emerge Memphis provides innovative and flexible office space solutions for growing businesses where new entrepreneurs can work alongside their professional peers. By supporting and strengthening the innovation ecosystem, we seek to grow the region's innovation economy.
Advance Memphis strives to bring economic revitalization in Memphis, Tennessee. We believe that adults can be empowered to change their lives and their community. Advance Memphis provides Biblically based programs that bring hope, knowledge, resources and skills to Memphis neighborhoods. The residents of each neighborhood then have the tools they need to affect change.
Downtown Creative District teeming with possibilities
The vision for a Downtown Creative District centers on the idea of a neighborhood where creative professionals thrive in a community of ideas.
INNOVA invests in early-stage, high-growth companies that have the potential to grow into significant economic contributors. Their focus is on companies with strong intellectual property or other competitive advantages in the Biosciences, Technology and AgriTech fields. Innova was created by the Memphis Bioworks Foundation to help establish Memphis as a national center of excellence in entrepreneurship. Innova's goal is to nurture the growth of high technology and entrepreneurial efforts that will result in significant job creation, economic growth and competitiveness.
Getting The Targets Right: Downtown Core, Vibrancy and Creative Millennials
Russ Williams, CEO of Archer>Malmo, made a presentation to the Downtown Memphis Commission about 10 days ago that should be a call to arms about the forces that will define in large measure whether Memphis will be economically competitive in the future – downtown vibrancy, a focus on the downtown core, and creative millennials.


From Rachael Ray Every Day, March 2019.
In a large bowl, toss the fennel, celery, onion, lemon juice, and EVOO; season with salt and pepper. Let the slaw marinate while you prepare the chicken.
Heat a large cast iron skillet over medium high. Season the chicken with salt and pepper. Add 2 tablespoons olive oil, two turns of the pan, to the skillet. Add the chicken. Cook until browned and cooked through, 3 to 4 minutes per side. Transfer to a plate. Reduce heat a bit and add the remaining 1 tablespoon olive oil, one turn of pan, to the skillet. Add the garlic and stir until aromatic, about 1 minute. Add the vinegar, sugar, rosemary, and Worcestershire and cook, stirring often, until reduced and thickened a bit, about 1 minute. Stir in the Dijon. Add the chicken and turn until coated. Cook until heated through, about 1 minute more.
Mix the arugula and parsley into the slaw. Serve the chicken whole or sliced with the slaw alongside.


The Cave City Planning Commission was formed to plan and promote a better Cave City. It's membership is comprised of the sitting City Council members and Mayor.
Interested citizens are encouraged to attend meetings and get involved in this important part of our community. Check out the events section for upcoming meetings.


Home is the most important asset for everyone. Insurance is the ideal way of protecting the house in a proper manner. There are many different kinds of policies for a different purpose. If you think that every insurance policy can cover the damage due to the hurricane, then let me clarify that this is not true. You have to find the perfect hurricane insurance policy by which you can protect the house in a proper manner.
Hurricane is one of the natural calamities, which doesn't come with any invitation. So, we should always be ready for handling the situations which can occur by these calamities. Well, a hurricane can bring two major problems which are wind and water. We can stay away from the tension of damage after having a suitable insurance policy.
What are the insurance policies for covering the hurricane damage?
As we know that hurricane can cause issues by wind or water and it totally depends on the place where you live. For covering the damage, you should first know about the different policies. These are basically described further, so read the complete article and grab the necessary details.
Windstorm insurance – there are some states which don't include the windstorm damage in the hurricane insurance. If you are living in any of these sates, then you just need to purchase a separate insurance policy for windstorm.
Flood insurance – there is no home insurance policy which includes floods. If you are willing to get the proper coverage from the damage due to flood, then you are required to purchase flood insurance. This is the only way by which you can get the claim for damage to happen by the hurricane.
Is It Possible To Go To The North Pole?
Seasoned adventurers that have seen all that the mundane world has to see have one place left on earth to explore— the North Pole. Many people are shocked to learn that it is indeed possible to plan a trip to the North Pole, but you do need a sense of adventure and a hefty wallet. Many have said it's a once in a lifetime opportunity to tread where few others have gone, and it is a trip well worth considering.
As one one of the most remote places in the world, getting to the North Pole can be tricky. Usually, ships are the most common mode of transportation. These ships are specifically designed to cut through ice in the Arctic Ocean and reach the Barneo Ice Camp. This so-called camp is run by Russian engineers that return each spring. The camp contains a landing strip for aircraft, and tourists that wish to see the North Pole can make it there by helicopter.


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My Dark Sky
Lifelong companion under the stars
The Missing Supernova in our Galaxy
Astronomers always say that our Milky Way Galaxy is long due for supernova – a violent stellar explosion when a star much more massive than our Sun dies, or when a white dwarf pile up sufficient materials from its stellar companion and causes a runaway nuclear fusion and explode.
According to observations of supernovae in other galaxies, astronomers estimated that there should be about three supernovae per century in our galaxy. But the last supernova known in Milky Way was Cassiopeia A, occurred around year 1680.
If the rate of supernova estimation is correct, we should be seeing about 10 supernovae between now and then. But we see none…
These missing young supernovae may imply that that our understanding of the relationship between supernovae and other galactic processes was in error, meaning the estimation was wrong; or maybe the problem lies in our galaxy – although it appears "normal from the outside", it may be different from other galaxies in some unknown way.
Or maybe the supernovae were there, but we just haven't found them… maybe they are hiding from us… and this seems to be the case, at least for one of them…
Recently, astronomers from NASA's Chandra X-ray Observatory and National Radio Astronomy Observatory's (NRAO) Very Large Array (VLA), have found a supernova remnant as young as only 140 years old, hidden behind a thick veil of gas and dust near the centre of our galaxy.
That's why we have not optically seen this object before. All the gas and dust there made it about a trillion times fainter, in optical light, than an unobscured supernova. This supernova remnant, called G1.9+0.3, can hide itself in optical, but it cannot hide itself in radio and x-ray; radio and x-ray could see through the murk easily.
This young supernova remnant is known by an uninteresting name: G1.9+0.3, located about 25,000 light years from us. This is a composite of the radio (blue) and X-ray (orange) images. Credit: Radio (VLA) and X-ray (Chandra).
This is not the first time astronomers observe G1.9+0.3. It was identified in 1985 as a supernova remnant, aged between 400 and 1000 years, by using the VLA. In 2007, another team of astronomers led by Stephen Reynolds observed the object again, this time using the Chandra X-Ray Observatory. To their surprise, their image showed the object to be about 16 percent larger than in the 1985 VLA image.
"This is a huge difference. It means the explosion debris is expanding very quickly, which in turn means the object is much younger than we originally thought," Reynolds explained. However, this expansion measurement came from comparing a radio image to an X-ray image.
To make an "apples to apples" comparison, the scientists sought and were quickly granted observing time on the VLA and their new VLA observations confirmed the supernova remnant's rapid expansion.
Comparison of VLA images of G1.9+0.3 in 1985 (left) and 2008 (right) clearly show the rapid expansion. Circle for size comparison. Credit: NRAO/VLA
But how does the rapid expansion tell us that this remnant is young?
We know that G1.9+0.3 expanded 16% in 23 years' time and by extrapolating that backward to a point, we can find all the expanding stuffs were in one point roughly 144 years ago. This is actually the maximum age – if the initial expansion was faster and was slowing down over time, maybe due to slamming into surrounding materials, G1.9+0.3 may be younger.
Now we know that young supernovae do exist in our galaxy, we can be sure that astronomers will look even harder to dig more of them out.
~ by thChieh on May 22, 2008.
Posted in Nebulae
Tags: Supernova
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LexisNexis Practice Guide: Connecticut Probate and Estate Administration is a practice-oriented resource that assists attorneys in handling every step of the probate and estate administration process.
LexisNexis Practice Guide: Connecticut Probate and Estate Administration is a practice-oriented resource that assists attorneys in handling every step of the probate and estate administration process. The authors share a wide variety of practice tips gathered through years of practice in this field. This practice guide includes in-depth analysis of topics such as: applicable Connecticut law, jurisdictional issues, probate proceedings, will challenges, intestate administration, asset inventory, claims against the estate and fiduciary management of the estate. Also included are all the forms, letters and other documents necessary for probate and estate administration.
James I. Dougherty is an attorney in the Estate and Trust Administration Department of Withers Bergman LLP, admitted to practice law in the State of Connecticut and the State of New York. He has had a lifelong involvement and passion for probate, tax, trust, and estate issues. He is a fourth generation attorney and has the privilege of carrying on the family tradition which began in 1930 of serving clients in his home State of Connecticut. He graduated from Carnegie Mellon University, Phi Beta Kappa, with University and College Honors. He earned his law degree from William & Mary Law School where he was awarded the George Wythe Award. In addition drawing on the collective decades of practice of trust and estates from his family, James was a summer clerk at a Connecticut Probate Court for four summers before joining Withers Bergman LLP. He assists executors and beneficiaries alike through all aspects of the estate administration process including probate, contested estates, contentious trust litigation, tax, and post-mortem estate planning issues. His practice also includes working with affluent individuals in the development and implementation of sophisticated planning techniques to help them accumulate, preserve, and transfer their wealth. James is a frequent author and speaker, nationally and internationally, on estate, trust, tax, and probate matters. He is a member of the Executive Committee for the Estates & Probate Section of the Connecticut Bar Association. James has been named as a Trusts & Estates Fellow for the Real Property, Trust & Estate Law Section of the American Bar Association for 2016-2018.
Louis R. Piscatelli is the head of Withers Bergman LLP's Estate and Trust Administration Department. He is admitted practice law in the State of Connecticut, the State of New York, and is a Registered Foreign Lawyer in the United Kingdom. Louis earned his bachelor's degree from Colby College and his M.B.A. from Cornell University. He obtained his law degree from the University of Connecticut graduating with high honors. Louis joined Withers Bergman LLP, what was then Bergman, Horowitz, and Reynolds PC, in 1987 and has been with the firm ever since. His practice focuses on estate and probate planning. He places a special emphasis on assisting families who own businesses create structures that are tax efficient and enables families to pass their wealth onto future generations. As head of the firm's department which handles decedent's estates and trusts, Louis has built a team over the years to help families through the estate administration process by providing solutions to the unique issues that present themselves in each estate.


Stream processing has become ubiquitous and Akka Streams, an implementation of the Reactive Streams specification, is one of the hottest kids on the block. In this talk we quickly cover the essential basics and then introduce advanced features like cyclic graphs and custom stream processing stages. Of course we use as few slides as possible and give a lot of attention to live coding a non-trivial stream topology which reliably consumes events.


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Baja! Got You All in Check: Honda Shows Baja-Racing Ridgeline at SEMA
When most folks think of Honda and racing on Mexico's Baja California peninsula, they think motorcycles. After all, Big Red has 24 two-wheeled victories in the grueling SCORE Baja 1000. Four-wheelers came into the mix only a decade ago, with a Ridgeline entered in the Stock Mini Class. Gavin Skilton wheeled it to class victory in 2008 and 2010. In 2012, they moved up to the ripping Class Six Trophy trucks with a tube-framed Pilot. Skilton and his brother, Darren, managed third place in the 1000 that year. And now Honda is heading back to the peninsula with a new truck, a Ridgeline-bodied Trophy Truck powered by a 550-horse twin-turbo version of the stocker's V-6.
Honda Performance Development and the Proctor Racing Group developed the truck. The turbo six up front displaces 3.5 liters and uses the 2017 Ridgeline's stock block, crank, and heads. Speaking of the 2017 Ridgeline, Honda helpfully notes that the front fascia, hood, roof, bed, and side profile incorporate cues from the upcoming pickup. Meanwhile, the Trophy Truck heads into battle shortly—the flag drops on the famed Mexican race on the morning of November 20.
["source-caranddriver"]
Baja! Got You All in Check Honda Shows Baja-Racing Ridgeline at SEMA	2015-12-22


And so, on Christmas Eve eve, we come to the last post in this 12 Blogging Days of Christmas series. I really hope you've enjoyed it, and that it's introduced you to some new talent.
We finish with Jacki from Adventures In Acetone, who did one of my favourite manis of this year - HERE. Lately, as a mother of 2, she's been doing a lot of swatching, so I'm really glad she got her art hat back on for this. Now she just needs to show me how to do it !!
I painted 2 coats of Milani White On The Spot and then went in with my striper art brush and Milani Rapid Cherry for the red details. I topped it with one coat of China Glaze Fairy Dust for some sparkle of the season and one coat of Poshe top coat. I hope you like it!


All businesses face risk. In today's hyper-competitive landscape, environmental, social and governance concerns should be at the forefront of any risk mitigation strategy. 72% of investors say that they value metrics on non-financial risk. Yet, 64% of portfolio companies are not adequately disclosing ESG risk. Considering that failures in any one of these areas can lead to loss, it's crucial for companies to know their ESG risk factors and to put structures in place to quickly deal with problems.
When Volkswagen defrauded American regulators in its emissions scandal, it was left with billions of dollars in criminal fees and a damaged reputation. BP is still suffering the fiscal and reputational consequences of its massive oil spill more than half a decade later while the affected communities and ecosystems struggle to recover. The wave of sexual harassment allegations across multiple industries should be a red flag for every brand. Organizations thrive on trust. When a crisis makes it to the front page, the fragile bond of trust is decimated.
Social responsibility, sustainability and corporate culture make a decisive impact on trust and accountability. As a CEO, recent high-profile scandals are a jarring reminder that we must always be ready to listen to our people and act on meaningful concerns.
This is not just a moral decision, but a business one. Harvard Business Journal found companies that successfully manage ESG risk outperform the market by 6%. These companies are able to head off problems before they become critical and act on new insights based on data. This leads to a significant return on investment for those companies that make ESG concerns a priority.
Employees are your eyes and ears. They are on the front line of your organization at every level. Offer them opportunities to give feedback and they will be the first to alert you to problems. Hazardous working conditions, inappropriate or unethical behavior, non-compliance— employees see it all. But they need a way to safely communicate. When we empower employees, not only do we avoid the possibility of huge losses, we increaseproductivity and fuel trust.
Too often, issues persist because employees fear retribution when voicing concerns. Whistleblowing solutions nurture trust and encourage valuable feedback. Look at Uber as a cautionary tale. Lawsuits, investigations, plummeting stock prices and trust— what might have been avoided if they had listened to employees and acted on those concerns?
Just like consumers, employees want transparency and integrity in the workplace. They need to know that their concerns are valued and will be acted on. If you want to know which ESG factors could be at risk, ask your people. You'll get more than just ESG data, you'll retain and recruit top talent and have an energized workforce. When you look out for employees, they will invest in the success of the company.
ESG data needs to be monitored across your entire organization— from the executive level down through the supply chain. This can be an immense challenge, but it's absolutely necessary in order to get an accurate picture. It's one thing to know about industry-specific risk factors. But you need to see what they look like on a practical level.
The only way to do this is with consistent monitoring. Known risk factors need to be monitored closely, and systems need to be responsive to the unforeseen. It's not enough to run through a checklist every six months. Your ESG monitoring needs to be on-going and adaptable. If there are health or safety concerns or misconduct in the office, I want to know about that today, not months from now. Without a real-time picture, we miss valuable opportunities to avoid loss and gain new insights.
Data is useless if not translated into action. That's why consistent, real-time monitoring is so important. Analyzing and understanding the feedback you gather is just as crucial.
First, you need to make sure that feedback gets to the right people. I want to be alerted to major concerns that affect operations, but I also want managers to be able to take action on issues under their control. Sorting and categorizing data after a concern comes in is inefficient and prone to error. Those systems need to be in place from the beginning to ensure a sufficient and speedy response.
Second, on a broader level, the ability to follow through goes back to trust. As a business owner, integrity means being accountable to consumers, employees and the communities we serve. We need to be concerned with the health and safety of our own people, but also think about our impact on the environment and the communities in which we operate.
This creates a cycle of investment and trust. When we care about our social and environmental impact, it leads to better standards of living. INSEAD's Global Private Equity Initiative (GPEI) found that in emerging markets, investment by some companies in better access to training, healthcare and schooling improved performance and positively impacted the bottom line.
A report by NYU Stern agreed that "...investors, if equipped with reliable, accessible information, are in a unique position to identify and reward companies with strong social performance, thereby creating incentives for companies across an industry to upgrade their operations in a way that improves human rights and strengthens societies."
ESG concerns are not only necessary for risk mitigation but also represent an opportunity to invest in consumer and employee trust.
Monitoring ESG can be a powerful tool for risk mitigation. That in itself is of enormous value. But as we've seen ESG insights also strengthen trust, improve performance, and make an impression on investors.
It's been shown that top ESG companies outperformed those at the bottom by 40%. For investors, accurate ESG data is a cue towards increased value. Investors want to see a strong risk mitigation strategy, as well as opportunities for growth. In such a competitive landscape, those companies that can demonstrate a detailed understanding of ESG data will have a unique advantage. Investors want to see non-financial risk analysis. Companies that can properly analyze and present ESG will be the most attractive in the market.
With increased scrutiny from regulators, consumers, and investors alike, companies must take a proactive role when it comes to ESG. Thankfully, new innovations and technologies make it easier for companies to monitor and analyze ESG data.
Our newest solution, ESG Pulse provides an audit trail across all ESG themes on one integrated platform. It's simple to use and allows for real-time monitoring. By utilizing feedback for ESG, we are able to gather data effectively and efficiently. Here at Questback, the system has allowed us to flag concerns and to take immediate corrective action.
The importance of ESG is ever-increasing. If you are able to understand the value and properly analyze your ESG risk factors, you'll be one step ahead when it comes to mitigating risk and finding new opportunities for growth. By staying one step ahead, businesses thrive in a competitive market. It's possible to make a profit and have a positive impact on communities. With better tools to track and measure ESG, there's no excuse not to.
ESG risks can make or break a company.
Frank joins Questback on the foundation of a distinguished career as an executive for SAS. Under his leadership, SAS received the prestigious "Great Place to Work" award; simultaneously, Frank received the Rosing Award and was named the IT executive of the year. Previously at PricewaterhouseCoopers, Frank's career is focused on enterprise analytics, leading in business intelligence, innovative technology, and transforming insight into results for international enterprises.


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Q: SQL Server : CASE does not work SELECT
   a.componentId, a.uniqueCode,
   'sd'= CASE
            WHEN RTRIM(LTRIM(b.name)) IS NULL OR RTRIM(LTRIM(b.uniqueCode)) IS NULL
               THEN isnull(b.uniqueCode,'')+isnull(b.name,'')
            WHEN RTRIM(LTRIM(b.name)) IS NULL AND RTRIM(LTRIM(b.uniqueCode)) IS NULL
               THEN isnull(b.uniqueCode,'')+isnull(b.name,'')
            ELSE b.uniqueCode + '(' + (b.name) + ')'
    END,
    a.specialization
FROM Doctors a
LEFT OUTER JOIN Territories b ON a.locationId = b.componentId;

Suppose b.uniqueCode = T003 and b.name = Dhanmondi 01, then sd should be T003(Dhanmondi 01).
Now if b.name = NULL then sd should be T003, but my query result shows T003().
What is wrong my T-SQL query?

A: Are you sure that b.name is null? If it has an empty string instead of null you would have the result you see. BTW, the rtrim/ltrim stuff is totally unnecessary when checking with is null and your second when will never happen because you will always end up in the first when if either column is null.
This will treat empty strings as null:
SELECT a.componentId, a.uniqueCode, 'sd'=
        CASE
            WHEN nullif(b.name, '') IS NULL OR nullif(b.uniqueCode, '') IS NULL
            THEN isnull(b.uniqueCode,'')+isnull(b.name,'')
            ELSE b.uniqueCode + '(' + (b.name) + ')'
        END , a.specialization
FROM Doctors a LEFT OUTER JOIN Territories b ON a.locationId = b.componentId;

A: Let's sort some basics out first...
Your second WHEN is impossible to reach, since the earlier WHEN will always be true (either null) before the second WHEN (both null).
RTRIM() and LTRIM() will only return NULL if the argument is NULL, so these two condition expressions are identical:

*

*RTRIM(LTRIM(b.name)) IS NULL

*b.name IS NULL
Removing redundant code, including the unreachable WHEN, will let you simplify your code considerably:
CASE
    WHEN b.name IS NULL OR b.uniqueCode IS NULL
        THEN isnull(b.uniqueCode,'') + isnull(b.name,'')
    ELSE b.uniqueCode + '(' + b.name + ')'
END

Now that we can read it...
The most likely explanation is that b.name is blank, not NULL.

A: In SQL and all of the popular SQL products - except Oracle - a NULL and an empty string '' are two different things. So, you should be checking both options:
SELECT a.componentId, a.uniqueCode,
    CASE
        WHEN b.name IS NULL OR b.name = ''
            THEN COALESCE(b.uniqueCode, '')
        WHEN b.uniqueCode IS NULL OR b.uniqueCode = ''
            THEN b.name
            ELSE b.uniqueCode + '(' + b.name + ')'
    END AS sd
     , a.specialization
...

or to remove leading and trailing spaces:
    CASE
        WHEN b.name IS NULL OR RTRIM(LTRIM(b.name)) = ''
            THEN COALESCE(RTRIM(LTRIM(b.uniqueCode)), '')
        WHEN b.uniqueCode IS NULL OR RTRIM(LTRIM(b.uniqueCode)) = ''
            THEN RTRIM(LTRIM(b.name))
            ELSE RTRIM(LTRIM(b.uniqueCode)) + '('
               + RTRIM(LTRIM(b.name)) + ')'
    END AS sd

redpajama_set_name: RedPajamaStackExchange


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Weathering this Storm: Paycheck Protection and Your Team
Jeff Gipson | April 16, 2020
Last week we spoke to the importance of being proactive, how keeping your recruiting efforts going during this time will allow your firm, agency or company to be prepared to take full advantage of the overflow of business poised to flow into the economy. You have built your team, person by person, talented piece by talented piece, designed it to generate your own brand of top-quality service. Everything you provide carries your signature because of them. They are essential.
The cost of losing someone is not only a massive financial hit but also means having to take the time to locate, evaluate and go through the essential—but costly—process of onboarding. Having to replace a member of a team you built, a team that knows and depends on each other, a group that feels the success of its individual members in a collective way, that is a disruption which takes valuable time to recover from.
The possibility of having to lose any valued leaders and staff to these circumstances is not a prospect any of us want to consider, but a situation doesn't just go away because we want it to. That being said, you have options that could allow you to preserve your company's current cultural dynamic and will provide some stability in an uncertain time.
PPP (Paycheck Protection Program)
A product of the CARES Act (Coronavirus Aid Relief and Economic Security), $349 billion has been put towards federally guaranteed business loans for institutions employing 500 people or fewer—including self-employed, sole proprietors and nonprofits. The program is designed to fund payroll and other operating expenses, such as employee healthcare and other benefits. There are a minimum of restrictions and if you use the funds to retain your current employees, the loans are not required to be repaid. Businesses have to have been in operation prior to February 15, 2020.
SBA Express Bridge Loans
The Small Business Association has developed an Express Bridge Loan Pilot Program which will allow those businesses already affiliated with an SBA Express Lender to get up to $25,000 quickly while waiting for a decision on the SBA Economic Injury Disaster loans offered to help business and homeowners to recover from declared disasters.
Economic Injury Disaster Loan Emergency Advance
The $10,000 advance is designed to provide relief to small businesses experiencing a temporary loss in revenue. It is available nationally and in all places that qualify for Economic Injury Disaster Loans. This program follows similar guidelines to PPP but may include businesses with more than 500 employees, depending on the industry, and if the application is successful, the advance does not have to be repaid.
The Small Business Association also offers a host of debt-relief options and more details on the aforementioned options on their website, sba.gov.
If you feel the way I do, the folks you've hired and taken the time to know professionally and personally are more than just some people who work for you. Your work family is not only essential in helping you carry out the work you're passionate about, but also a huge support system in your life. Keeping your work family together is not just a professional imperative that keeps your business going the way you like, delivering what you need it to; it is an effort that will benefit both your professional and personal lives.
At The James Allen Companies, we want you to be aware of every possible program and resource that will keep you whole and help you weather this difficult economic period.
Jeff Gipson
Jeff Gipson Sr. is a veteran of the staffing industry, with more than 30 years of experience. He got his start working for an international staffing organization where he focused on information technology placements across the country. In July 1992, Jeff continued his staffing career with a St. Louis based information technology staffing company. There, he was strategically involved in launching the organization's first branch office — and subsequently three additional branch offices over the next several years. In July 2000 Jeff made another move — this time to launch his own staffing company, continuing his IT focus. In 2003 the organization was reinvented. Relying on his earlier sales career in the insurance industry, the company changed course and began building the firm around the insurance industry. The company continues to put all their energy in the insurance sector filling positions of all titles across the country. Jeff and his wife Carolyn have been married since 1980. They have three children and seven grandchildren.
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About - Classic Remodeling NW, Inc.
WE BUILD DREAMS IN THE SEATTLE, EASTSIDE & EVERETT, WA AREAS!
At Classic Remodeling NW Inc. our mission is to build life long relationships with our clients, co-workers, neighbors, and peers through the home remodeling process. Our guiding principals are those of commitment, honesty and personal accountability through a high level of communication and respect for one another. We are truly honored to be a part of this experience and to give you support when you most need it. Join our family today!
BUILDING YOUR VISION, YOUR WAY.
Classic Remodeling NW has been in business for over a decade and has the experience to turn your vision into the perfect home for you and your lifestyle. We are ready to get started on your dream home.
Ward's passion for building began in the construction industry at the age of 13 working for an insulation company. After four years in the U.S. Army as a combat engineer, Ward began working for an 'old school' craftsman, learning the true value of quality and exceptional customer service. After passing the State of California Contractor Exams in 1988 and operating a small one-man-shop Ward relocated to the Northwest in 1997. This was the beginning of Classic Remodeling NW Inc. Ward's enthusiasm for construction, extensive knowledge, and many years of experience have made Classic Remodeling NW Inc. the successful business that it is today. Ward truly enjoys working with each and every customer. By listening with 'two ears' before using his 'one mouth' he turns dreams into reality.
All designations by the National Association of Home Builders.
Ward Hampson (the owner), SaDora (owner's wife), Maryann, Rebecca, Russell, Joe, Paul, and Curtis.
We are all eager to work with new clients from all over western Washington and provide you with the best level of service you've ever experienced.
Ward Hampson (the owner), SaDora (owner's wife), Maryann, Rebecca, Joe, Paul, and Russell.
READY TO GET STARTED ON YOUR HOME REMODELING PROJECT OR CUSTOM BUILT HOME?
From beginning to end Classic Remodeling was very professional, responsive and very likeable. Ward and Mike were very easy to work with in every respect. Communication was clear and they lived up to everything they promised. We would highly recommend them to anyone and will definitely use them again in the future.


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A Louis XV gold, harsdtone, abalone, mother of pearl and silver-gilt mounted snuff box, By Antoine Daroux, Paris 1747
Posted by alaintruong2014 in Silver, Gold Boxes & Objects of Vertu
Antoine Daroux, Louis XV
A Louis XV gold, harsdtone, abalone, mother of pearl and silver-gilt mounted snuff box, By Antoine Daroux, Paris 1747. Estimate £20,000 – 25,000 (€25,000 – 32,000). Photo Bonhams.
Rectangular, the cover set with a mother of pearl panel relief carved with a scene of a tented army camp inlaid with gold, agate abalone shell and stained mother of pearl to depict an officer being offered a drink by a maid from a barrel within a silver-gilt frame with wavy moulded edges, the side panels with similarly decorated mother of pearl panels depicting marshal trophies, the underside panel with an officer at rest under a tree surveying both inlaid and engraved rows of tents, height 4cm, length 8cm.
Notes: The State Hemitage in St Petersburg holds a box by Etienne Trenel, Paris 1749-50, that has similarly moulded gold mounts and uses the same technique of relief decorated mother of pearl panels that are inlaid with further coloured mother of pearl, gold and hardstones, cat. no. 56 in Jewellery of France from the 18th to early 19th centuries(The State Hermitage Publishers 2012). This box was also illustrated by Snowman, plates 240 and 240A, Eighteenth Century Gold Snuff Boxes (London 1990). The scenes depicted are Chinoiserie but the style and technique are almost identical, especially the leaf canopies of the trees.
A box with almost identical military camp iconography was sold by the late Baron Maximilien de Goldschmidt-Rothschild and the Baronne de Becker, Sotheby's Monaco, 29th November 1975, ex lot 136. The cover of the box has a scene of millers filling sacks of grain whilst the underside has the same three conical-form tents with a standing guard.
Bonhams. FINE SILVER AND GOLD BOXES, 12 Nov 2014 11:00 GMT – LONDON, NEW BOND STREET


The update adds Continuity Camera support and non-Mojave-specific features.
Another PowerPoint project in dark mode.
Selecting a file in PowerPoint in dark mode.
An almost-blank document in Word in dark mode.
A blank Excel document in dark mode.
Another Excel document in dark mode.
More of Outlook in dark mode.
Unfortunately, OneNote still doesn't support dark mode.
Microsoft has released version 16.20.18120801 of Office 365 for the Mac platform, bringing support for a couple of key Mac features introduced in September's macOS 10.14 Mojave release, as well as a number of small features and user experience improvements not related to Mojave.
The headline feature is, of course, dark mode support, which requires Mojave to work. Word, Excel, PowerPoint, and Outlook all support Mojave's dark theme. Also related to Mojave, you can now use Apple's Continuity Camera feature to insert a photo directly from your iPhone's photos to a slide in PowerPoint.
Take a photo and then add it.
Open an editable document on your Mac in PowerPoint.
Select where you want to insert the photo by control-clicking in the document.
You can only take standard photos—no square mode, no video modes, no filters, no HDR or Live Photo options—images are always sent to your Mac as jpegs rather than HEIF files to maximize compatibility, and images are saved at a lower-than-native resolution with the phone's EXIF data stripped out.
Most of the notable additions that don't require Mojave are for Outlook. You can click on a meeting event in your calendar to see a list of attendees or disable forwarding of meeting invites by attendees to keep your meetings from ballooning to include people you don't want. There's also support for creating Microsoft Teams meetings directly from Outlook, the ability to share your calendar with other people, and a new multiple-time-zone view for the calendar for up to three time zones.
Microsoft also expanded the proofreading tools in PowerPoint with grammar suggestions. In Microsoft Word, you can now check a box labeled "Embed fonts in file" to make sure that your document looks as intended on the computers it's viewed on, even if the target computer didn't already have all the necessary fonts. This feature was already added to PowerPoint back in September.
Microsoft has updated Office 365 for Mac monthly for some time. Last month, the company added Web picture support directly in Word, Excel, and PowerPoint; new mail encryption features for Outlook; and a new view in PowerPoint, called "summary zoom."
However, some major changes, like a total overhaul and redesign of Outlook, are still pending in future updates.


Stackers are a favourite amongst the littlies and Janod has created a stacker with a sense of adventure! Multikub Stacking Farm has 5 wooden characters to role play including a farmer, cow, horse, rabbit and chicken. 5 boxes made from sturdy card that can be stacked on top of each other or used separately as a playset also include a rooster on a weather vane. Each box depicts a different building on the farm with cut-outs for doors and windows to interact with the figures and numbers on the top to assist with counting and number recognition. Once play is finished they can all be stored neatly inside the largest box, just pop on the barn roof and place on the shelf.